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HIPAA Patient Consent Form

HIPAA Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you.

The Notice contains a Patient’s Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office, or going to our Website. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such revocation shall not affect any disclosures we have already made in reliance on your prior Consent.

The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Patient understands that:

  • Protected health information may be disclosed or used for treatment, payment or health care operations.
  • The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
  • The Practice reserves the right to change the Notice of Privacy Policies.
  • The Patient has the right to restrict the uses of their information.
  • The Patient may revoke this Consent in writing at any time and all future disclosures will then cease.
  • The Practice may condition treatment upon execution of this Consent. No insurance can be billed on the patient’s behalf without this signed HIPAA consent form, therefore same day of service payment in full for any services will be required.